Section Ins 9.27 - Preferred provider plan requirementsInsurers offering a preferred provider plan shall comply with all the following:
(1) Except as provided in s. Ins 9.25(2), insurers offering a preferred provider plan that apply a coinsurance percentage when the services are performed by nonparticipating providers at a different percentage than the coinsurance percentage that is applied when the services are performed by participating providers shall offer plans that have either of the following: (a) The coinsurance differential between participating and nonparticipating providers performing the same services is 30% or less.(b) The coinsurance differential between participating and nonparticipating provider performing the same services is greater than 30% and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25(5).(2) Except as provided in s. Ins 9.25(2), insurers offering a preferred provider plan that apply a deductible when the services are performed by nonparticipating providers in a different amount than the deductible that is applied when the services are performed by participating providers shall offer plans that have either of the following: (a) The deductible applied to nonparticipating providers is no more than 2 times greater than the deductible applied to participating providers or no more than $2000 higher than the participating provider deductible.(b) The deductible applied to nonparticipating providers is more than 2 times greater than the deductible applied to participating providers or is more than $2000 higher than the participating provider deductible and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25(5).(3) Except as provided in s. Ins 9.25(2), insurers offering a preferred provider plan that apply a co-payment when the services are performed by nonparticipating providers in a different amount than the co-payment that is applied when the services are performed by participating providers shall offer plans that have either of the following: (a) The co-payment applied to nonparticipating providers is no more than 3 times greater than the co-payment applied to participating providers or no more than $100 for services of a health care provider or no more than $300 for services of a health care facility.(b) The co-payment applied to nonparticipating providers is more than 3 times greater than the co-payment applied to participating providers or is more than $100 for services of a health care provider or is more than $300 for services of a health care facility and the insurer provides the enrollee with a disclosure notice that is compliant with s. Ins 9.25(5).(4) This section first applies to an insurer offering a preferred provider plan beginning on January 1, 2007. This section does not apply to an insurer with respect to a preferred provider plan issued prior to January 1, 2007 and periodically renewed after December 31, 2006.Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.27
CR 05-059: cr. Register February 2006 No. 602, eff. 3-1-06; emerg. cr. (4), eff. 9-1-06; CR 06-118: cr. (4) Register April 2007 No. 616, eff. 5-1-07.